CMS Price Transparency Data

Occupational therapy (self-care training)

Facility: UPMC Northwest

Billing Code: 97535 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 97535
Insurance Median: $68
Cash Discount Price: $65
vs. Medicare Baseline: 2.10x Medicare

The contracted insurance negotiated median rate for a Occupational therapy (self-care training) at UPMC Northwest is $68. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $65. Compared to the federal Medicare reimbursement reference rate of $32.4, this hospital’s rate is 2.10x the Medicare baseline. Located in 100 Fairfield Drive, Seneca, PA.

Cash / Self-Pay

$65

Average discount available for prompt cash payment at this facility.

Insurance Median

$68

Median negotiated contract rate across all mapped commercial carriers.

Medicare Reference Rate

$32.4

Standard federal government reimbursement rate for this code.

Visual Cost Comparison vs. Medicare

Medicare Reference Baseline: $32.4 (100%)

Cash / Self-Pay: $65 (201%)

Insurance Median: $68 (210%)

Cash: $65 (201% of Medicare)

Ins. Median: $68 (210% of Medicare)

Understanding this gauge: We use the federal Medicare rate of $32.4 as the cost baseline. Rates below the baseline represent excellent value. In-network commercial rates commonly hover around 150% - 250% of Medicare, while rates exceeding 300% are elevated. Hover over the green and blue markers to view detailed calculations.

Elevated Commercial Rate Alert (Value-Gap)

The negotiated rate at this facility is 210% of the Medicare baseline (a markup of 110%). Patients with high-deductible plans or out-of-network benefits may face excessive out-of-pocket costs.

Consult Patient Advocate

Out-of-Pocket Cost Estimator

Estimate whether it is more economical to use your insurance or pay the upfront self-pay cash rate.

Billing Status

Remaining Deductible ($)

Your Coinsurance Rate (%)

Input your details and click calculate to compare out-of-pocket costs.

Commercial Insurance Negotiated Rates

Negotiated contract ranges established by major commercial carriers at this facility.

Carrier / Plan Group	Contract Rate Range	vs. Medicare Reference
Aetna	$27 - $70	83%
Cigna	$43 - $70	133%
Upmc Work Partners	$43	133%
Highmark Wholecare (Prev Gateway)	$54	167%
Pa Health & Wellness	$59	182%
Blue Cross Blue Shield	$66 - $81	204%
Intergroup	$70 - $3,704	216%
Coventry/First Health	$76	235%
Health Coalition Partners	$78	241%
Private Health Care Systems	$86	265%
Humana	$92	284%
Upmc Health Plan	$103	318%

Self-Pay Upfront Cash Action Plan

Request a "Self-Pay classification" with the billing desk before receiving care.
Ask for a written "Prompt-Pay Discount" agreement quoting the price of $65.
Request and sign a "Waiver of Insurance Submission" to prevent automatic billing.
Verify CPT Code matches exactly: 97535.

Insurance In-Network Protection Plan

Contact your insurance company to confirm UPMC Northwest is fully in-network.
Ask your insurer if "Prior Authorization" is required for CPT code 97535.
Confirm the specific physician or imaging center is also in-network (not just the hospital building).
Audit your Explanation of Benefits (EOB) against the final itemized hospital invoice.